SAP/CHILD STUDY Referral Form

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The following is an anonymous referral form. You are not required to share your identity, but may if you choose. Please be as detailed as possible when explaining your concerns- we will use it to determine if it is SAP or Child Study related.
If this is an EMERGENCY and you feel the student may be an immediate threat to themselves or others, please contact school counselor, administration, or nurse immediately.

Student: *

Grade:

9th

10th

11th

12th

Other:

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Referred By: (optional)

Reason(s) for Referral

Please select all that apply.

Suspected Child Abuse/Neglect

Witness to (or Victim of) Traumatic Event

Behavior

Physical Appearance

Poor/Inappropriate Peer Relationships

Gender Identity Issues

Drugs/Alcohol

Attendance

Academic

Required

Comments:

Please provide a brief description of the observable evidence of the reason(s) selected above.

Submit

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